SKIN AND SOFT TISSUE

INFECTIONS
 CASE PRESENTATION
• 65 year old male
• Known hypertensive, type 2 diabetic
• Current treatment: Metformin, Losartan
• Presents with right lower limb swelling and
pain for 1 day
• What further history would you like to obtain?
 Further History
• Acute onset; Preceded by history of fever and chills.
• Reddening of the leg
• No history of trauma; No use of immunosupressive agents
• Reported bloody discharge from the medial aspect of the
ankle. No purulent discharge.
• No recent history of travel/immobility. No dyspnea/chest
pain. No history of hormone replacement therapy

• Past Medical History: Underwent amputation of the right

big toe in November 2017 due to osteomyelitis. During
discharge, stump was reportedly clean.
 Examination
• Diaphoretic
• No pallor/jaundice/cyanosis
• Not in respiratory distress
• BP 148/68 PR 81 RR 16 T 36.1 (Had a fever spike later
of 39)
• Right lower limb swollen and erythematous at the leg
and ankle. Tender.
• Medial aspect of the ankle: serosanguinous discharge
from underlying bulla.
• Big toe amputated (Bloody discharge from site)
• Differentials
 X-ray of right foot and ankle

• Doppler ultrasound shows no features of DVT

• MRI
– Features in keeping with subacute osteomyelitis involving the first
metatarsal bone with intramedullary and soft tissue abscess.
– Pyomyositis and second digit osteomyelitis
 Classification of SSTIs
• Nonpurulent
– Cellulitis and Erysipelas
– Necrotizing infections
• Purulent
– Cutaneous abscesses
– Furuncles and Carbuncles
– Inflamed Epidermoid cysts
• Others: Surgical Site infections, Animal bites,
Bartonella infections, Erysipeloid, Glanders,
Tularemia, SSTIs in immunodeficiency
 Cellulitis & Erysipelas
• Erysipelas:
– Cellulitis involving the face only
– Upper dermis and superficial lymphatics
– Clearly visible and palpable borders

• Cellulitis
– Deeper dermis and subcutaneous fat
Protective Factors in
Healthy Skin
Risk Factors
 Clinical Features
• Acute onset (Erysipelas); Indolent (Cellulitis)
• Nearly always unilateral
• Erysipelas: Butterfly involvement; Milian’s ear
sign; Step sign
 Evaluation
• Blood cultures/cutaneous aspirates/swabs
recommended in:
– Patients with malignancy on chemotherapy
– Neutropenia
– Severe cell-mediated immunodeficiency
– Immersion injuries
– Animal Bites
– Severe systemic features (High fever, hypotension)
Management
 Impetigo
• Most common in children 2 – 5
years
• S. aureus, β hemolytic strep
(A,C,G)
• Bullous, non-bullous and
ulcerative (ecthyma) forms
• Post-infectious sequelae: PSGN,
RF
• Evaluate with Gram stain and
culture of pus/exudates
• Topical mupirocin/retapamulin
(5d)
• Oral therapy for numerous
lesions or in outbreaks (7d)
– Depends on isolation from
culture/ suspicion of MRSA
 Cutaneous Abscesses
• Risk factors similar to cellulitis + risk factors for
MRSA colonization
• S. aureus (75%)
• Painful, fluctuant, erythematous nodule
– ± surrounding cellulitis / regional adenopathy
– ± spontaneous drainage
• Treatment: I&D; systemic antibiotics if
– Severely impaired host defenses, S/S of systemic
infection, multiple abscesses, extremes of age, lack of
response to I&D.
 Case
• A 63-year-old woman is evaluated for fever and hypotension 4 days after kidney-pancreas
transplantation surgery. She was treated with cyclosporine, prednisolone, and
mycophenolate mofetil. The incisional pain has not increased, and, except for slightly
increased erythema surrounding the incision, there are no localizing signs or symptoms.
Medical history is significant for type 1 diabetes mellitus since the age of 12 years. Until the
onset of her current symptoms, she had been doing well after surgery.
• On physical examination, temperature is 39.4°C (102.9°F), blood pressure is 88/52 mm Hg,
pulse rate is 100/min, and respiration rate is 20/min. Cardiopulmonary examination is
normal. On abdominal examination, there is erythema surrounding the surgical right lower
quadrant incision and moderate tenderness to palpation of the surgical wound. The
remainder of the examination is normal.
• Laboratory studies show hemoglobin, 12.1 g/dL (121 g/L); leukocyte count, 13,400/µL (13.4
× 109/L); creatinine, 1.9 mg/dL (168 µmol/L); urinalysis, 7 leukocytes/hpf, 25
erythrocytes/hpf, and trace protein.
• The patient and organ donor are serologically positive for cytomegalovirus infection.
• A chest radiograph reveals no infiltrates. Abdominal radiographs show only a small amount
of free peritoneal gas. CT scans of the chest and abdomen reveal only some peri-incisional
fluid.
• Which of the following is the most likely cause of this patient's current symptoms and
findings?
• A. Candidal wound infection
B. Cytomegalovirus infection
C. Pneumocystis jirovecii pneumonia
D. Staphylococcal wound infection
 Surgical Site Infections
• Most common adverse event affecting
hospitalized surgical patients
• Occur within 30 days after surgery (usually
>48 hours after surgery)
• Classification
– Superficial incisional SSI
– Deep incisional SSI
– Organ/space SSI
Management of SSIs
 Management of SSIs
• Suture removal and I&D
• Adjunctive Abx if associated significant systemic
response (Erythema & induration extending >5cm
from wound edge/ T>38.5/HR>110/WBC>12000
• Add Abx against MRSA if high risk factors
• If following surgery in
axilla/GIT/perineum/Female genital tract: Use
agents against Gram negative bacteria and
anaerobes
 Case
• A 39-year-old woman is evaluated in the emergency department for fever, myalgia, and malaise 2
days after her pet dog bit her on the left lower extremity. Medical history is significant for a
splenectomy 5 years ago following a motor vehicle accident. She has received tetanus,
pneumococcal, meningococcal, and Haemophilus influenzae type B vaccines, and her dog's
immunizations are up-to-date. There are no allergies, and the remainder of the medical history is
noncontributory.
• On physical examination, temperature is 38.7°C (101.7°F), blood pressure is 90/60 mm Hg, pulse rate
is 110/min, and respiration rate is 26/min; BMI is 26. There is erythema and tenderness at site of the
puncture wound on the left thigh. An abdominal laparotomy scar is noted. There is no inguinal
lymphadenopathy. The remainder of the physical examination is normal.
• Laboratory studies show hemoglobin, 10.0 g/dL (100 g/L); leukocyte count, 16,600/µL (16.6 × 109/L)
with 56% neutrophils, 33% band forms, 10% lymphocytes, and 1% monocytes; platelet count,
17,500/µL (17.5 × 109/L); peripheral blood smear, many Howell-Jolly bodies; blood urea nitrogen, 40
mg/dL (14.3 mmol/L); creatinine, 2.4 mg/dL (212.2 µmol/L); alanine aminotransferase, 500 U/L; and
aspartate aminotransferase, 450 U/L.
• Multiple blood cultures reveal growth of gram-negative rods/bacilli. The urinalysis is normal.
Radiographs of the left femur show no gas or foreign body.
• Which of the following is the most likely cause of this patient's septic presentation?
• A. Capnocytophaga canimorsus
B. Escherichia coli
C. Salmonella species
D. Staphylococcus aureus
E. Streptococcus pyogenes
 Soft Tissue Infections due to Dog and
Cat Bites
• Evaluation
– Blood culture
– Plain radiographs (to evaluate bony structures and
presence of foreign bodies)
– MRI (for deep/severe infections – evaluate for
abscess/osteomyelitis/septic arthritis/tendinitis)
• Wound Care
– Saline irrigation; removal of debris; surgical evaluation;
leave infected wounds open after debridement
• Antibiotic prophylaxis (Indications? Regimen?
Duration?)
• Tetanus Immune Globulin and Tetanus toxoid; Rabies
prophylaxis
 Necrotizing Soft Tissue Infections
• Classified as:
– Necrotizing cellulitis
– Necrotizing myositis
• Clostridial myonecrosis
• Polymyositis
– Necrotizing fasciitis
• Fulminant tissue destruction with systemic
signs of toxicity
Diagnostic Algorithm for Necrotizing Soft tissue Infections
Pitfalls in the Diagnosis of Necrotizing
Soft-Tissue Infection
 Classification of Necrotizing Fasciitis
Mainly extremity and truncal

Misiakos et al., Current Concepts in the management of necrotizing fasciitis.

Frontiers in Surgery, 2014
 Group A Streptococci (S.pyogenes)

Electron microscopy of Group A M-type streptococci

Cunningham MW. Pathogenesis of Group A Streptococcal Infections.
Clinical Microbiology Reviews, 2000
 Virulence of Group A Streptococci
• Adhesins (F1, F2, SfbI, SfbII, FbaA, FbaB)
• Spreading factors (Inflammatory related enzymes):
– Hyaluronidase (spreading factor)
– Streptokinase (fibrinolysin)
– Dnase (streptodornase)
• Hyaluronic acid capsule (Antiphagocytic, nonantigenic)
• M Protein
– Antiphagocytic and anticomplement
– Mimics that of mammalian muscle and connective tissue
• Hemolysins:
– Streptolysin O: Immunogenic, Cytotoxic to leukocytes;
Hemolytic
– Streptolysin S: Non immunogenic, Cytotoxic, Hemolytic

Cunningham MW. Pathogenesis of Group A Streptococcal Infections.

Clinical Microbiology Reviews, 2000
 Pathogenesis

• Infection begins in hypodermis/superficial

fascia
• Synergistic action of virulence factors of
bacteria and specific host factors
– Aerobic bacteria cause platelet aggregation and
induce complement fixation
– Anaerobic bacteria produce collagenase and
heparinase that promotes formation of clots
– Bacteroides: Inhibits phagocytosis of aerobic
bacteral
Clinical Features
 Investigations

• Don’t delay definitive treatment (surgery) due to

investigations
• Leukocytosis/Leukopenia with left shift
• Features of AKI
• Elevated creatine kinase
• Blood cultures
– Positive in 60% in type II
– Positive in 20% in type I
• Imaging: Soft tissue radiograph/CT/MRI
• Finger test
 Treatment
• Surgical mgt is the primary modality of mgt
– Timing and extent of 1st debridement – most important risk
factor for mortality
• Empiric Antibiotic treatment
– Aerobic (including MRSA) and Anaerobic cover
– Vancomycin/Linezolid/Daptomycin + Piperacillin-
tazobactam/carbapenem/(ceftriaxone+metronidazole)/(Fluoroq
uinolone+Metronidazole)
• Streptococci: Penicillin + Clindamycin
• S.aureus: Nafcillin/oxacillin/cefazolin/vancomycin
(MRSA)/clindamycin
• Aeromonas hydrophila: Doxycycline +
ciprofloxacin/ceftriaxone
• Vibrio: Doxycycline + ceftriaxone/cefotaxime
 Clostridial Myonecrosis (Gas
Gangrene)
• Classification
– Traumatic gas gangrene (70%)
• C. perfringens (80%)
• Bowel/biliary tract sx, Gunshot wounds, compound #, abortion,
retained placenta, PROM, IUFD
• Trauma introduces organisms into deep tissues

– Spontaneous gas gangrene (30%)

• C. septicum & C.tertium
• Congenital/cyclic neutropenia, Prior radiation Tx to abdomen, Ca
colon, IBD, Diverticulitis, GI surgery, Leukemia, lymphoproliferative
disorder, chemotherapy, AIDS, NEC/ileitis
• Hematogenous seeding of muscle from GIT portal of entry
Clostridium Perfringens - Virulence
 Clostridial Myonecrosis
• Sudden onset of severe pain
• Skin pale initially  Bronze
appearance  Purple/red
discolouration
• Tense and tender
• Overlying bullae
• Systemic toxicity: Fever,
tachycardia, shock,
multiorgan failure
• Complications: shock, AKI,
jaundice, liver necrosis
 Evaluation and Treatment
• Imaging (radiography/CT/MRI) – Gas in deep tissues
• Blood and tissue (+bullous fluid) M/C/S
– G +ve ; Absence of frank pus; Absence of neutrophils
• Surgical Exploration (with debridement)
– Muscle that doesn’t bleed/contract when stimulated;
Muscle tissue edematous and discoloured
• Broad spectrum ABx before diagnosis
– Vancomycin + Piperacillin-tazobactam/Ampicillin-
sulbactam/carbapenem
• Definitive: Penicillin + Clindamycin
• Duration: Until no further debridements needed and
normal hemodynamic status.
 Pyomyositis
• Pus within individual muscle groups
• Risk factors: Immunodeficiency, Trauma,
Injection drug use, Concurrent infection,
Malnutrition
• S.aureus (90%), Grp A Streptococci
• Indolent course
• Fever, pain and cramping localized to
affected muscle
• Evaluation
– Cultures of blood and abscess material
– Imaging (most useful for diagnosis)
• MRI preferred (Alt: CT/US)
• Repeat imaging in persistent bacteremia to
identify undrained focus of infection
• Empiric Abx: Vancomycin
– Add cover against G-ve bacilli in
immunocompromised patient/following
open trauma to muscles